Genu recurvatum as a complication after total knee arthroplasty.

A 73-year-old female patient underwent total knee arthroplasty for arthrosis. After surgery, recurvatum instability over 55 degrees occurred. Two years later, primary endoprosthesis was removed and a revision endoprosthesis implanted. However, complete deformity occurred again. Two years later, the thickest revision polyethylene tibial implant was implanted on the same endoprosthesis. In spite of using knee orthosis, recurvatum deformity returned. Seven months later, new revision rotating hinge prosthesis was implanted. This procedure seems to have solved the problem. The knee deformity in this specific case was larger than the deformity in cases reported so far, and it was solved after three surgical procedures. Rotating hinge prosthesis seems to be the method of choice for immediate repair of recurvatum instability after total knee arthroplasty.

Complications after hip rearthroplastics with revision endoprosthesis.

The stability of the revision endoprosthesis components is more difficult to achieve than in primary endoprosthesis due to large bone defects and/or decreased bone mass quality. That is the reason for more frequent complications for revision than in primary arthroplasty. The aim of this study was to investigate the frequency of complications in 122 patients who were operated with the revision endoprosthesis in the Department of Orthopedics in University Hospital Split in the period of 1998 to 2007 and accepted to participate in this study. There were 3 patients treated on bought hips. The average follow up time was four years (0.6-10.6). There were 32 (26.2%) males and 90 (73.8%) females. The average age was 70.66 +/- 7.63 years. The average time from operation to physical therapy was 3.53 +/- 2.56 days. There were 27 (21.6%) complications. The most common complication was infection in 9 (7.2%) cases. From those cases, 4 (3.2%) had superficial, and 5 (4%) had deep infection. From other complications, there were 5 (4%) endoprosthesis reluxations, 2 (1.6%) periprosthetic femur fractures, 5 (4%) urinary infections, and 6 (4.8%) other complications (lung mycroembolia, heart infarction, lumbal plexus lesion from L2, spinal cord infarction with paraplegia, pneumonia and severe sacral bed-sore). There were 10 (8%) re-interventions following the revision arthroplasty. The result was good or excellent in 80% of operated patients, satisfied in 17%, and bad in 3%. The revision hip procedures are characterized with a high complications incidence rate. Our results are comparable with the results from literature.

The influence of femoral head shift on hip biomechanics: additional parameters accounted.

Pauwels' method of hip biomechanics can explain a negative influence of the lateral shift of the femoral head on the load of dislocated hip joint, but, the influence of the cranial shift of femoral head can not be explained. A calculation of hip balance which takes into consideration both lateral and cranial shifts of the femoral head is presented. Two pelvic radiographs were used; of an adult person and of a two year old child. One hip was normal, and other was dislocated. Force R was established using horizontal lever k(1), and a new vertical lever k(2). Graphically and mathematically the results show that the force R is always greater in the dislocated hip. Both lateral and cranial shifts contribute to this. The modification of Pauwels method described clearly demonstrates that not only lateral but also cranial shift of the femoral head in dislocated hip should be taken into consideration.

[Total knee arthroplasty in the cardiac transplant patient--a case report]. / Aloartroplastika koljena u bolesnika s transplantiranim srcem--prikaz bolesnika.

We present a 66 year-old diabetic patient who 4 years ago underwent cardiac transplantation and 1 year ago was implanted a total knee arthroplasty due to arthrosis. In the literature and reference books the arthroplasty in such patients is mainly related to aseptic necrosis of the joints as a result of taking immunosuppressive therapy (corticosteroids). Our patient didn't have an aseptic necrosis but a classical arthrosis of the knee. Although our patient didn't have so strong pain as patients with aseptic necrosis, we decided to do the knee arthroplasty. The procedure went properly and postoperative time, recovery and knee function were excellent. Implantation of endoprosthesis in a cardiac transplant patient shouldn't be retained only for cases of aseptic necrosis of a joint, which occurs due to immunosuppressive therapy, but also for the cases of classical arthrosis. Good preoperative, perioperative and postoperative care and good surgery technic make this procedure safe in cardiac transplant patients as in nontransplanted patients. To the best of our knowledge this is the first case of implantation of knee endoprosthesis in a cardiac transplant patient in Croatia.

[Postoperative closed suction drainage following hip and knee aloarthroplasty: drain removal after 24 or after 48 hours?]. / Poslijeoperacijska drenaza nakon aloartroplastike kuka i koljena: odstranjivanje drenaze nakon 24 ili nakon 48 sati?

The use of closed-suction drainage systems after total hip and knee replacement is a common practice. It is believed that drainage reduces the haematomas and infection. The usual time to remove drains is 48 hours. Usefulness of the long time drainage of the haematomas and possible harmfulness of infection is still a subject of discussion. In this article, using our own operative material, we want to show the justification of the 48 hour duration of closed-suction drainage. The investigation was done on the patients with hip replacement (45 patients) and knee replacement (11 patients). The amount of blood in the drainage systems in the first 24 hours after the surgery and after 24 hours till the removal of drainage was observed. The results show that the amount of blood lost in the drainage system in the first 24 hours was on average 95.29%, and only 4.71% in the next 24 hours. This article supports the opinion that postoperative drainage has to be removed after 24 hours, i.e. the 48 hours-drainage seems not to be justified.

[Has femoral neck fracture in older patients to be treated with reposition of fragments and osteosynthesis or with primary aloarthroplasty?]. / Treba li prijelom vrata femura u starijih bolesnika lijeciti repozicijom i osteosintezom ulomaka ili primarnom aloartroplastikom kuka?

In this article we analised and compared the efficiency of operative treatment of the femoral neck fracture in two groups of patients, over 70 years of age, treated on different way. The first group were the patients treated by osteosynthesis of the fracture site, and the second group were the patients treated by aloarthroplasty of the hip. All patients had surgery over three days after injury. We found that the group of patients with osteosynthesis had twice bigger unsuccessful results (62.5%) in relation to the group treated with hip aloarthroplasty (31.8%). The relation between the number of reoperations after osteosynthesis and hip aloarthroplasty was 8:1. We also found that radiological healing ot the fracture site after osteosynthesis happened only in 10% cases. Patients treated with hip aloarthroplasty earlier started to walk without help (1.9 months after surgery) and the patients treated with osteosynthesis could walk five times later (10.59 months after surgery). Although neck femoral fractures in older patients are treated ten times more with hip aloarthroplasty than with osteosynthesis, int his article we showed that hip aloarthroplasty must be the first choice in mostly all patients over 70 years of age. Osteosynthesis has to be used very rare, in patients with lateral neck fractures without dislocations, and it must be done as emergency procedure, not later then 48 hours of injury.

Relevant sonographic parameters of a painful shoulder in symptomatic dialyzed patients versus asymptomatic dialyzed and healthy volunteers.

The aim of this study is to find dialysis relevant sonographic parameters of painful shoulder of the symptomatic dialyzed patients comparing them with parameters in asymptomatic dialyzed patients and healthy volunteers. Significant difference in all metric parameters (thickness of supraspinatus tendon, diameter of biceps tendon sheet and capsula-bone distance) were noticed between all groups and the symptomatic had the highest values. Asymptomatic had the higher values then volunteers. Inhomogenicity of the tendon and biceps tendon sheet effusion in the symptomatic patients were the most often occurred. Subdeltoid effusion, deposits and tendon rupture were found only in symptomatic patients. No difference in presence of calcifications between symptomatic and asymptomatic was found. Metric parameters are relevant and associated with dialysis, as well as biceps tendon effusion tendon inhomogenicity, deposits and subdeltoid effusion. Tendon ruptures are relatively rare and nonspecific.

[Bilateral ulnar pseudoarthroses in an adult]. / Obostrana pseudoartroza ulne u odrasle osobe.

A case is presented of a 30-year-old woman with right ulnar fracture who developed pseudoarthrosis after conservative treatment. Healing occurred after osteosynthesis. Four years later she sustained fracture of the left forearm. Conservative treatment resulted in ulnar pseudoarthrosis, whereas radius healed well. The ulna healed after osteosynthesis. Six years later she had refracture of the right ulna, distally to the site of fracture and pseudoarthrosis 10 years before. Conservative treatment led to pseudoarthrosis of the right ulna again. Osteosynthesis produced good result. The case is interesting, because the same person suffered ulnar fracture on three occasions (twice on the right and once on the left), without intensive trauma, and pseudoarthrosis developed each time after conservative treatment, whereby classic osteosynthesis solved the problems. There are no similar report in the literature. The question is whether the patients had normal bone structure, and whether conservative treatment should be done as a standard theapeutic modality in ulnar fractures.

[Suppurative coxitis after a viper bite--case report]. / Gnojni koksitis nakon ujeda poskoka--prikaz bolesnice.

A 46-year-old woman having sustained a rhinoceros viper bite to the left lower leg is presented. She was treated at Department of Infectious Diseases, Split University Hospital. After 20 days she left the hospital in good condition, with a small crust at the bite site. About ten days later suppurative secretion developed at the bite site and a few days later she felt pain in her right hip and leg, and turned febrile. She was treated at home with antibiotics and analgetics for nearly one month. Her condition was worsening, and she was referred to Department of Neurosurgery, for suspected lumboischialgia. Then, she was transferred to the Department of Orthopedics as suspected septic coxitis, where she was operated on. The disease was not recognized on time, appropriate treatment was introduced too late, and irreparable consequences developed in the right hip. To the best of our knowledge, this is the first reported case of coxitis, especially on the contralateral side to the snake bite. Infection from the site of snake bite on the left lower leg could have been transferred to the right hip exclusively by hematogenous way. Our objective is to warn of this rare snake bite complication, and to contribute to better diagnostic and therapeutic management in similar situations.